Fill - Free fillable Newport News Police Department (City of Newport News) PDF form

Newport News Police Department

Applicant Background

Form # 139 Revised 07/15/2015

You have

been selected to proceed to the next step of the selection process for a position with

the Newport News Police Department. To avoid automatic disqualification for failing to

submit required information and making scheduled appointments, please complete the attached

background investigation form and submit the form no later than the date provided to you.

You can assist us in providing prompt dispositions on the status of all applications by

observing the following mandatory instructions:

• Do contact the recruiter if the recruiter requests, if you relocate your residence,

change jobs, are no longer interested in the process, or you have another job offer you

wish to consider.

• Do not call the Newport News Police Department to ask about the status of your

application. Due to the volume of applicants, you will be notified in writing or by

phone of the disposition of your application if you are a police ap

plicant.

• Do not ask the Background Investigator the status of your background investigation.

They are not permitted to reveal any details to anyone other than supervisors within

their chain of command.

Your cooperation is imperative in this process. You will be contacted at the conclusion of

the selection process which may take up to one year. Thank you.

**Please keep this page for your records

Newport News Police Department

Recruitment Unit

9710 Jefferson Avenue

Newport News, Virginia 23605

757-928-4150

Page 1 of 16

Newport News Police Department Applicant Background

Page 2 of 16

BACKGROUND INVESTIGATION FORM

NEWPORT NEWS POLICE DEPARTMENT

This form must be typewritten or clearly printed in black ink. All questions must be answered, if applicable. If

not, indicate N/A (not applicable). Forms which are not complete and legible will not be considered. If space

provided is not sufficient for complete answers, or you wish to furnish additional information, attach additional

sheets of the same size as this form, and refer to the questions answered.

Name (first, middle, last):

Date:

Position Desired:

Home

Phone:

Other Names Used*:

Other

Phone:

*(nicknames, aliases, maiden name, former names changed legally or otherwise)

Present Street Address: City:

State: Zip Code: E-Mail:

Date of Birth

(mm/dd/yy):

Place of Birth (City, State):

Social Security #:

Driver's License #: State: Expires

Gender: Male Female

Natural Hair Color: Eye Color:

REQUIRED DOCUMENTATION

Background/application processing cannot be completed without the following documentation. Originals must

be reviewed for verification along with copies for inclusion in the applicant's file. Official transcripts are the

only documentation accepted to substantiate education (no grade reports or unofficial transcripts will be

accepted). Military members must submit copies of past military evaluations to document past performance

during the last three years of military service. Applicants with prior law enforcement experience must provide

evaluation/performance reports for the three most current years of employment, if applicable. Salary policy may

allow for adjustment in base pay scale for sworn within 60 days of employment, provided documentation is

made available and the Chief of Police has reviewed and approved such requests.

Appl

icants will be asked to provide copies of the following documentation:

• Dri

ver’s License

• High school transcript and College transcript

• Birth certificate

• Social security card

• DD214 for any military service and copies of military evaluation or performance reports

• Relevant training certificates; Any other documentation submitted for consideration at the discretion of the

applicant

Copies must be submitted by the applicant upon request. Do not submit documentation until requested

by the Background Investigator.

NNPD Form 139

Revised 07/2015

Newport News Police Department Applicant Background

Page 3 of 16

MILITARY SERVICE

ave you ever been a member of the Armed Forces (US or foreign)?

Branch of Service: Service #:

Date of Entry: Date of Discharge:

Place of Discharge:

Rank Upon Entry: Rank Upon Discharge:

Reserve Obligation: Active Inactive Until:

Type of Discharge:

List any convictions in any military courts received:

Date Command Location Nature of conviction Disposition

AMILY DATA

Present marital status: Single Married Widowed Separated Divorced

If married, widowed, separated or divorced (present or former spouse):

Name: Social Security # :

Address: City: State:

Date of Birth: Place of Birth:

Date of Marriage: Place of Marriage:

Place of Spouse Employment:

Business Address:

Occupation: Business Phone:

If divorced, give date, name and location of court granting the decree:

ate: ________________________________ City/State: ___________________________________________________

Name of Court Granting Decree: _______________________________________________________________________

ist the names, ages and relationship of all persons living with you:

Name Age Relationship

NNPD Form 139

Revised 07/2015

Newport News Police Department Applicant Background

Page 4 of 16

FAM

ILY DATA CONTINUED

Father’s Name: Date of Birth:

Address: Occupation:

Mother’s Name: Date of Birth:

Address: Occupation:

Father-in-Law's

Name:

Date of Birth:

Address:

Occupation:

Mother-in-Law's

Name:

Date of Birth:

Address: Occupation:

st the names, ages, addresses, and occupations of all brothers and sisters:

Name:

te of Birth:

Address: Occupation:

Name: Date of Birth:

Address: Occupation:

Name: Date of Birth:

Address:

Occupation:

st your addresses for the past ten years. If you have served in the Armed Forces, list your duty stations while

in the military. Start with the present address and attach additional sheets of paper if necessary.

From: To: Street Address:

City: State:

From: To: Street Address:

City: State:

From: To: Street Address:

City: State:

From: To: Street Address:

City: State:

From: To: Street Address:

City: State:

From:

To:

Street Address:

City: State:

From: To: Street Address:

City:

State:

From: To: Street Address:

City: State:

NNPD Form 139

Revised 07/2015

Newport News Police Department Applicant Background

Page 5 of 16

EMPLOYMENT

1. Start with your present employer and list all previous employment for the last 10 years, including periods of

unemployment. If known, provide current phone numbers for past supervisors. Please attach additional

sheets if needed.

om:

To: Em

ployer:

Phone: Your Title:

Address:

Supervisor Name, Title

and Phone number:

lary:

Explain in detail the

reason for leaving:

From: To: Employer:

Phone: Your Title:

Address:

Supervisor Name, Title and

Phone number:

lary:

Explain in detail the reason

for leaving:

From: To: Employer:

Phone:

Your Title:

Address:

Supervisor Name, Title

and Phone number:

lary:

Explain in detail the

reason for leaving:

From: To: Employer:

Phone: Your Title:

Address:

Supervisor Name, Title

and Phone number:

lary:

Explain in detail the

reason for leaving:

2. Have you ever been fired or dismissed from a job?

Yes No If you answered yes, please explain.

NNPD Form 139

Revised 07/2015

Newport News Police Department Applicant Background

Page 6 of 16

3. Have you ever quit a job before you were about to be fired?

Yes No If you answered yes, please explain.

4. Have you ever been reprimanded by any supervisor for being late or absent?

Yes No If you answered yes, please explain.

5. Have you ever been reprimanded for misconduct or for unsatisfactory performance?

Yes No If you answered yes, please explain.

6. Have you ever disclosed confidential information to an unauthorized person?

Yes No If you answered yes, please explain.

7. Have you ever falsified or altered any official document?

Yes No If you answered yes, please explain.

NNPD Form 139

Revised 07/2015

Newport News Police Department Applicant Background

Page 7 of 16

ACCIDENT AND TRAFFIC VIOLATION RECORD

1. Have you ever been ticketed, cited, summonsed for any violation of traffic laws, including traffic infractions

such as speeding, or driving under the influence of drugs or alcohol?

Yes No If yes, please explains.

Date of Ticket: City, State Disposition:

2. Do you have any unpaid parking tickets in this state or any other state?

Yes No If yes, please explain.

3. Do you have a valid driver’s license? Yes No

If yes, State and license number: Class of license:

How long have you been a licensed driver? Date first issued a license:

Does your license contain any restrictions? Yes No If yes, please explain.

List previous licenses from other states: (include dates)

4. Has your driver’s license ever been suspended or revoked in this state or any other state?

Yes No

If yes, please explain.

5. Have you ever had to attend a training school because of a motor vehicle charge or criminal arrest?

If yes, please explain.

NNPD Form 139

Revised 07/2015

Newport News Police Department Applicant Background

Page 8 of 16

6. List all accidents you have had as the operator of a vehicle. Include dates, city and state, if investigated by

the police, and if a ticket was issued.

Date of Accident: City, State Investigated by Police? Ticket Issued?

Yes No Yes No

7. Were you under the influence of alcohol before any of the above listed accidents occurred?

Yes No

8. Have you ever been involved in a hit and run accident? Yes No

If yes, please explain.

9. Do you have any lawsuits pending because of an accident? Yes No

If yes, please explain.

10. Have you ever been denied auto insurance? Yes No

If yes, please explain.

ARRE

STS AND/OR UNDETECTED CRIMES

1. Have you ever had any contact with any police authority in any jurisdiction? (Victim, Reporting Person,

tness, Offender)

Yes No

If yes, please explain.

2. Have you ever committed/participated in any of the following crimes? Include crimes you ever committed in

which you were not caught?

Murder Yes No Burglary Yes No Manslaughter Yes No

Rape Yes No Larceny Yes No Sex Crimes Yes No

Robbery Yes No Arson Yes No Sale of Drugs Yes No

Pedophilia Yes No

Any Alcohol Related Offense (Drinking in Public, DUI, Drunk in Public, Underage Possession, Contributing to

minors such as alcohol, drugs, etc.)

Yes No

If yes, please explain.

NNPD Form 139

Revised 07/2015

Newport News Police Department Applicant Background

Page 9 of 16

3. Have you ever been involved in:

Terrorism Yes No

Gangs Yes No

A criminal enterprise Yes No

Child pornography Yes No

Conspiracy to commit a serious crime Yes No

If yes, please explain.

4. If you have ever been charged or arrested for any criminal offense (as a juvenile and/or as an adult), you

ust list below any charges or arrests (other than expungement), regardless of deferred findings or dismissal of

charges for any reason.

Yes No

5. Have you ever been served a summons to appear in court? Yes No

If yes, please explain.

6. Have you ever been in jail or prison? Yes No

If yes, please explain.

7. Have ever stolen anything in the following manner?

Shoplifting/ Merchandise Yes No Employer Yes No

Residence Yes No Government Yes No

Receive stolen goods Yes No From other persons Yes No

From parents/ relatives Yes No Money Yes No

If yes, please explain.

8. Have you ever been involved in any type of situation for which someone could blackmail you?

Yes No

If yes, please explain.

NNPD Form 139

Revised 07/2015

Newport News Police Department Applicant Background

Page 10 of 16

GAMBLING

1. Have you ever placed a wager/bet by telephone or made a hand-to-hand transaction with a bookmaker

(bookie or numbers man) on the results of a sports event? ( i.e. football, basketball, baseball, hockey, horse

race) Yes No

If yes, please explain.

2. Have you ever worked for a bookmaker? Yes No

If yes, please explain.

3. Do you currently have any gambling debts? Yes No

If yes, please explain and how much?

ILLEG

AL SUBSTANCES

1. Are you currently using illegal drugs or other illegal controlled substances? Yes No

If yes, please explain.

2. Have you ever sold, bought or possessed (touched) marijuana? Yes No

If yes, please explain: Include dates:

3. When was the last time you were in the presence of marijuana or other illegal drugs?

Include dates:

4. Have you ever sold, bought or possessed (touched) any of the following felony drugs or any illegal

substance: Cocaine, LSD, Heroin, Psilocybin, Spice or Bath Salts. or any hallucinogen, designer drugs, speed

or steroids. Yes No

If yes, please explain and how much?

3. Have you ever used, sold, bought or possessed someone else’s prescription medication?

Include type of medication and dates: (ie. Pain medication, ADHD medication etc.)

NNPD Form 139

Revised 07/2015

Newport News Police Department Applicant Background

Page 11 of 16

FINANCIAL STATEMENT

1. Are you currently meeting your financial obligations? Yes No

2. Have you ever been contacted by a collection agency regarding any outstanding unpaid debt, charge off

account, collection account, foreclosure, delinquent account, civil judgment, repossession garnishment or tax

lien?

Yes No

If yes, please explain.

3. Have you ever been sued in court for a collection of any debt contracted by you? Yes No

If yes, please explain.

4. Have you ever filed for bankruptcy? Yes No

If yes, please explain.

5. Have you ever had any judgments against you, and/or is there any pending at this time? Yes No

If yes, please explain.

6. List your current debts or financial obligations:

Amount To Whom Owed Monthly Payment Item(s) Purchased

NNPD Form 139

Revised 07/2015

Newport News Police Department Applicant Background

Page 12 of 16

GENERAL INFORMATION

List all other employment applications, to include previous applications to the Newport News Police

Department, other law enforcement agencies, and fire or rescue departments to which you have applied for

employment. List a point of contact and a telephone number and/or email address. Include the date of

application and current status. (i.e. on list, failed written test, etc.)

A current application with other departments does not affect your application with Newport News Police

Department. Failure to disclose other applications may eliminate you from the process.

2. Have you previously served as a law enforcement officer? Yes No

If yes, state in what capacity, where, when and why you left.

3. Do you have any relatives, friends or acquaintances employed by any law enforcement, fire or rescue agency

or department? If so, give their name, agency, location and position.

Name

Agency

City & State

Phone number

Position

4. Do you have any specialized training, police training or hold any special license or permit?

If so, please list.

5. Do you use or have you ever used any type of tobacco products? Yes No

If yes, what type?

6. Do you have any visible tattoos? Yes No

NNPD Form 139

Revised 07/2015

Newport News Police Department Applicant Background

Page 13 of 16

EDUCATION

List all high schools, colleges, universities, professional and trade schools attended. Give dates of attendance,

name of institution, location and course of instruction. If you graduated, type of degree or diploma.

High

School & Trade School

om:

To: Sc

hool:

City: State: Graduated:

Course

Pursued:

pe of Degree:

From:

To:

School:

City: State: Graduated:

Course

Pursued:

pe of Degree:

From: To: School:

City:

State:

Graduated:

Course

Pursued:

pe of Degree:

lleges & Universities

om:

To: Sc

hool:

City: State: Graduated:

Type of

Degree:

Credit Hours: GPA:

From: To: School:

City: State: Graduated:

Type of

Degree:

Credit Hours: GPA:

From: To: School:

City: State: Graduated:

Type of

Degree:

Credit Hours: GPA:

NNPD Form 139

Revised 07/2015

Newport News Police Department Applicant Background

Page 14 of 16

REFERENCES

1. List the name, address and phone number of FIVE personal references not related to you and have known

ou for at least four years: Do not use former supervisors as references.

Name

Address

Phone number

Years Known

Name

Address

Phone number

Years Known

Name

Address

Phone number

Years Known

Name

Address

Phone number

Years Known

Name

Address

Phone number

Years Known

2. List any clubs, social or fraternal organizations, civic or community groups, professional or trade unions or

associations which you are currently a member of or have been involved with in the past.

NNPD Form 139

Revised 07/2015

Newport News Police Department Applicant Background

Page 15 of 16

BEFORE SIGNING THIS FORM, BE SURE THAT ALL THE INFORMATION YOU DISCLOSE TO THIS

DEPARTMENT REPRESENTS THE ENTIRE TRUTH AS IT RELATES TO THE QUESTIONS ASKED.

ANY MISREPRESENTATION GIVEN BY THE APPLICANT WILL BE IMMEDIATE GROUNDS FOR

TERMINATION OF EMPLOYMENT OR DISQUALIFICATION OF THE APPLICANT FOR

EMPLOYMENT. YOU MUST BE COMPLETELY CANDID, AND PROVIDE, WITHOUT ANY

OMISSION WHATSOEVER, ANY INFORMATION REQUESTED VERBALLY OR IN WRITING BY THE

POLICE DEPARTMENT OR THE CITY OF NEWPORT NEWS REGARDING YOUR APPLICATION. DO

NOT OMIT ANY INFORMATION.

ou are seeking employment with the City of Newport News and are subjected to a background investigation by

a representative of the Newport News Police Department. Be advised of the following:

he Newport News Police Department Investigator is involved in the process to the extent of conducting

background investigations and interviews. The Investigator assigned to conduct your background investigation

is not authorized to release any information regarding this process to you or anyone outside of their chain of

command. The Investigator is not authorized to offer employment to an applicant and no statement made by the

Investigator shall be construed as a job offer to the applicant. I, the above named applicant, certify that I have

filled out this background investigation form, and understand the questions and information requested, and that

all information provided by me, as well as any information provided by me verbally or in any supplementary

submission, is true, accurate and complete, to the best of my knowledge. I understand that providing false,

misleading, or incomplete information, regardless when discovered, constitutes grounds for my disqualification

for City employment or termination from City employment.

________________________________

Signature of Applicant Date

I the above signed, certify that the information given is true and accurate to the best of my knowledge.

NNPD Form 139

Revised 07/2015

Newport News Police Department Applicant Background

Page 16 of 16

CITY OF NEWPORT NEWS

AUTHORIZATION FOR RELEASE OF INFORMATION

TO: Any Doctor, Physician, Psychologist, Psychiatrist, Dentist, Hospital, Nursing Home, Medical

Association, Health Clinic, Attorneys at Law.

. S. Armed Forces, Maritime Service, Veteran Administration, or U. S. Selective Service.

ny Academic Dean, Registrar, Principal, Guidance Counselor or authorized person at any:

School, College, University, Business School, Trade School, High School, Elementary School

(public or private) or any institution involved in education.

ny State, Local, Federal Law Enforcement Agency.

Any Judge, Court, or Magistrate.; Any State, Local, City or County agency.

ny past or present employer.

ank, Credit Union, Credit Bureau, Retail Merchants Association or Lending Institution.

ny person(s) having knowledge regarding my character or reputation.

_______________________________________________________________________________________

Name Address

__________________________________________________________________________________________

City State Zip Code

ve applied for employment with the Newport News Police Department. I am aware that my entire background

is to be investigated thoroughly. I hereby authorize and direct the release of any and all requested information

you may have concerning me (including transcripts of records and copies of documents) to any City of Newport

News Police Investigator or Human Resources Representative upon presentation of this release form. I

understand that any such information is considered confidential by the Newport News Police Department and

will not be released to me.

also certify that any person(s) who may furnish such information concerning me shall not be held accountable

for giving this information; and I do hereby release said person(s) from any and all liability which may otherwise

be incurred as a result of furnishing such information. I also authorized the release of any and all information

regardless of any agreement, expressed, verbal or in writing, I may have made with you previously to the

contrary.

photocopy of this release form will be valid as an original thereof, even though the said photocopy does not

contain original writing of my signature.

igned this ____________ day of ___________________ the year ________________

ate of Birth___________________________ SSN#_______________________.

_________

___________________________ _______________________________________

Signature (Include maiden or previous name) E-Mail Address

FOR EMPLOYMENT PURPOSES ONLY

NNPD Form 139

Revised 07/2015

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